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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201130
Report Date: 04/26/2023
Date Signed: 04/26/2023 11:33:49 AM


Document Has Been Signed on 04/26/2023 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PROCARE RETIREMENT HOME,LLCFACILITY NUMBER:
079201130
ADMINISTRATOR:MARYGRACE C ODENAFACILITY TYPE:
740
ADDRESS:208 SAN ANTONIO WAYTELEPHONE:
(925) 378-7896
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee May MunarTIME COMPLETED:
11:45 AM
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At 9:00 AM on 04/26/2023, Licensing Program Analyst (LPA) J Sampair arrived unannounced for a visit concerning Unusual Incident Report (UIR) dated 04/25/2023. Upon entry, LPA explained purpose of the visit to Licensee May Munar.

At 9:15 AM on 04/26/2023, LPA met with Licensee about the UIR. Licensee stated that she and her staff members were "working with the daughter [W1] to come up with a proper solution for her mother [R1]."

From what Licensee shared, LPA stated that this was a change in condition, for which, according to regulation, R1 required a re-evaluation by her physician and an update to her appraisal needs and services plan.

Licensee agreed. She promised to inform W1, who will be visiting that afternoon, of the need for the re-evaluation by her mother's physician as soon as she is able to do so.

Exit interview conducted with Licensee. Copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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